epidemiologist Mark Dworkin of the University of Illinois. however, Later,C. and New Delhi “I hope this report by ‘one of their own’ helps bring attention to the fact that this is not an esoteric medical problem … but rather a global ecological problem that affects us all” The report’s authors contend the economic case for tackling AMR is strong In addition to its health toll by 2050 AMR could cost the world $100 trillion in lost economic output they argue By contrast acting on the recommendations in the report such as supporting the development of new antibiotics and diagnostics and strengthening surveillance could cost as little as $3 billion to $4 billion a year about 005% of what the G20 countries spend on health care today The experts call for a two-tiered approach: Lower the use of available antimicrobials and increase the supply by stimulating the development of new ones For instance improved hygiene faster and better diagnostics and new vaccines could reduce unnecessary use of antibiotics The authors also advocate a worldwide campaign to educate people about the dangers of resistance to keep patients from demanding antimicrobial drugs and doctors from prescribing them—an idea Laxminarayan endorses The report urges that some critical antibiotics not be used in agriculture at all where the drugs are commonly given to livestock to treat infections or boost growth Certifying meat as raised with “responsible use” of antibiotics could allow consumers to drive down their use Nicholas White a malaria researcher at Mahidol University in Bangkok says he expects pushback from the agricultural sector To counter that he says there is a critical need to “support trials of alternative approaches in the agro industry” The report also offers concrete suggestions on how to boost the development of drugs effective against resistant infections Many pharmaceutical companies have abandoned antimicrobial drug development because it is not very lucrative Global sales of patented antibiotics are roughly $47 billion a year—about as much as a single top-selling cancer drug the authors note A Global Innovation Fund endowed with up to $2 billion is needed to fund early-stage research; a bonus of $1 billion for a company that develops a new drug that is effective against resistant infections could also help The money could be raised as a levy from these companies through a “pay-or-play” strategy in which companies can either pay up or invest it in research and development to fight AMR Laxminarayan says he is “curious” about the pay-or-play idea “On the face of it it is interesting but leaves a lot to be determined in how AMR-relevant research is defined” he says White adds that in low-income countries many people particularly children still die because they do not get much-needed antibiotics; he calls for redirecting some of the money to be spent fighting resistance toward delivering antibiotics to these neglected patients Andrew Read an evolutionary biologist based at Pennsylvania State University University Park who studies resistance says the report is “a call to action and we sure need that” But although curbing the use of unnecessary antibiotics is important he thinks the bigger challenge is learning to use the drugs when needed in a way that doesn’t select for resistant strains “If evolutionary considerations became an essential component of medical best practice we’d get immense gains—even bigger than those that will come from rapid diagnostics and less agricultural use”

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